Balancing Hospital Care and Patient Sleep Needs

Anyone who has been a hospital patient knows one undeniable truth: it is impossible to get a good night’s sleep. Daily labs are drawn at 1:00 AM. Chatter and alarms flood the hallways. It is no wonder that patients often respond negatively to entreaties about sleep quality. As third-­‐year medical students, we often hear something to the effect of, “I’d have slept better if you guys hadn’t woken me up 20 times last night!” Living in a world where Flux will adjust the intensity and color of your computer screen to promote better sleep at night, the question stands -­‐ how is it that sleep is often ignored in hospitals, our places of healing? In this reflection, we delineate the negative consequences of disrupted sleep in patients, highlight the largest contributing modifiable factors, and offer solutions to this pervasive problem.

Patients and providers understand that sleep deprivation is a nuisance. Patients ranked sleep deprivation as their third greatest fear after only pain and intubation1. Providers understand the need to perform essential care tasks at night, but 88% of 1,220 of those surveyed agreed that poor sleep negatively impacts healing and therapeutic response1. A 2004 study reported an average of 42.6 overnight care interactions in critical care units, namely monitoring of vital signs and inputs/outputs2. Sitting outside a busy standard patient room on the 5th Floor of the Gibbon building, we observed 21 nighttime care interactions between 9:00 PM and 7:00 AM alone.

What effect does sleep deprivation have on the human body? As it turns out, the effects are wide-­‐ranging for a variety of patient populations. After one day of sleep deprivation, COPD patients experience a significant decline in FEV1, FVC and maximal inspiratory pressure3. Sleep-­‐deprived cardiac patients demonstrate surges in stress hormones that drive up their heart rate and increase their risk of heart attack4. Immunologically, studies have shown that as little as two nights of sleep deprivation produces deficits in cells responsible for innate and cellular immunity5. The inability to rest also unsettles the body’s metabolic equilibrium, decreasing insulin sensitivity6.

Reinforcing circadian rhythms in the hospital – i.e. exposing patients to light during the day and maintaining darkness at night – has been studied in a wide variety of contexts with tangible results for patients and hospitals. A 2005 study of post-­‐operative patients found that those on the “sunny” side of the hospital used 22% less analgesic medications per hour, producing a 21% decrease in pain medication costs per patient7. Care coordination and prudent workflow adjustments can even reduce the use of nighttime sedatives from 32% to 16%8. Lighting patterns to mirror day-­‐night cycles reduce agitation in dementia patients, shrinks length of stay for cardiac patients, and reduces depression in psychiatric patients9.

 Berk Ilhan, 10XBeta, Brooklyn NY

Berk Ilhan, 10XBeta, Brooklyn NY

While not every issue negatively impacting patient sleep is modifiable, minor changes can decrease the amount of disruptive noise and light overnight in the hospital. A 1998 ICU reported that 49% of major noise in the ICU was attributed to talking and televisions10. When providers in the ICU adjusted their behaviors (i.e. conducting team meetings away from patient rooms), 75% of the 24-­‐hour care cycle became significantly quieter. Light stimuli, especially the 4000K blue-­‐ and red-­‐ enriched lighting that is used at Jefferson, is especially effective a driving down melatonin production in the brain11. With each flick of the light switch, the body’s natural mechanisms for sleep are destroyed. Practitioners can help reduce unnecessary light stimuli by rounding later in the morning, keeping the lights off during questioning, and remaining cognizant of the times tests and medications are carried out12.

Although its etiologies are multifactorial, sleep deprivation makes it harder for patients to heal, produces increased medication costs, and, ultimately, impacts patient outcomes. Simple modifications in hospital workflow, from noise reduction to reduced light disruptions, have been shown to produce demonstrable improvements in sleep quality in the hospital. As a world-­‐class academic medical center, Jefferson can demonstrate empathy for those receiving care here by respecting the role of rest in effective healing.

About the Authors

Graham Hale and Timothy Bober are medical students in the Sidney Kimmel Medical College Class of 2018.

Citations

1.     Kamdar BB, Needham DM, Collop NA. Sleep deprivation in critical illness: its role in physical and psychological recovery. J Intensive Care Med. 2012;27(2):97-­‐111.

2.     Linda M. Tamburri, Roseann DiBrienza, Rochelle Zozula, and Nancy S. Redeker. CE Article and Journal Club Feature: Nocturnal Care Interactions with Patients in Critical Care Units. Am J Crit Care March 2004 13:102-­‐113

3.     Phillips BA, Cooper KR, Burke TV. The effect of sleep loss on breathing in chronic obstructive pulmonary disease. Chest. 1987;91(1):29-­‐32.

4.     Liu Y, Tanaka H. Overtime work, insufficient sleep, and risk of non-­‐fatal acute myocardial infarction in Japanese men. Occup Environ Med. 2002;59(7):447-­‐ 51.

5.     Dinges DF, Douglas SD, Zaugg L, et al. Leukocytosis and natural killer cell function parallel neurobehavioral fatigue induced by 64 hours of sleep deprivation. J Clin Invest. 1994;93(5):1930-­‐9.

6.     Spiegel K, Tasali E, Leproult R, Van cauter E. Effects of poor and short sleep on glucose metabolism and obesity risk. Nat Rev Endocrinol. 2009;5(5):253-­‐ 61.

7.     Walch, Jeffrey M., et al. "The effect of sunlight on postoperative analgesic medication use: a prospective study of patients undergoing spinal surgery."Psychosomatic Medicine 67.1 (2005): 156-­‐163

8.     Bartick, M. C., Thai, X., Schmidt, T., Altaye, A., & Solet, J. M. (2010). Decrease in as-­‐needed sedative use by limiting nighttime sleep disruptions from hospital staff. Journal of hospital medicine, 5(3), E20-­‐E24.

9.     Joseph, Anjali. The impact of light on outcomes in healthcare settings. Center for Health Design, 2006.

10.  Douglas M. Kahn, DO; Thorley E. Cook, DO; Carol C. Carlisle, RN, AB; David L. Nelson, CRTT; Naomi R. Kramer, MD; and Richard P. Millman, MD, FCCP. Identification and Modification of Environmental Noise in an ICU Setting. Clinical Investigations In Critical Care. Volume 114, Issue 2, August 1998, Pages 535–540

11.  Fucci, Robert L., et al. "Toward optimizing lighting as a countermeasure to sleep and circadian disruption in space flight." Acta Astronautica 56.9 (2005): 1017-­‐1024.

12.  Olson DM, Borel CO, Laskowitz DT, Moore DT, Mcconnell ES. Quiet time: a nursing intervention to promote sleep in neurocritical care units. Am J Crit Care. 2001;10(2):74-­‐8.